Cancer Screening and Diagnosis Quiz

Staging, Grading, and Clinical Investigations

• The presentation is about staging, grading, and clinical investigations for various cancers.
• The learning outcomes include understanding the diagnostic stage of the patient pathway for common cancers, exploring the role of cancer programs, appreciating the range of diagnostic tools, understanding how prompt diagnosis impacts prognosis, and understanding staging and grading mechanisms.
• Prevention involves strategies and measures that stop cancer from developing, while screening involves checks for disease before symptoms appear.
• UK screening programs include bowel cancer, breast cancer, and cervical cancer.
• There is no national screening program for prostate cancer in the UK, though PSA tests can be requested by men over 50 after discussion with a GP.
• Lung health checks, including CT of the chest, are offered to high-risk patients in England and Wales.

Detection and Diagnosis

• Signs are objective findings perceived by an examiner; symptoms are subjective findings perceived by the patient.
• Identifying a disease, or condition, is called diagnosis.

Patient Interview

• Patient interviews help establish events leading to the symptoms, including a medical history review and review of familial history.

Possible Symptoms (C.A.U.T.I.O.N)

• Change in bowel or bladder habits
• A sore or ulcer that doesn't heal
• Unusual bleeding or discharge
• Thickening or lump in breast or elsewhere
• Indigestion or difficulty swallowing
• Obvious change in a mole or wart
• Nagging cough or hoarseness of voice

Self-Examination

• Breast cancer self-examination
• Self-exam of the testicles

Physical Examination

• Inspection
• Palpation
• Vital signs

Diagnostic Tests - Lab Studies

• Normal FBC Levels: Data provided for adult men and women.
• Urine tests
• Stool samples
• Sputum samples
• Blood tests for tumor markers (PSA, AFP, BTA, BRCA1 and BRCA2, CA15, CA125)
• Other common tumor markers

Diagnostic Tests - Imaging

• Nuclear Medicine
• Plain X-rays
• Computed Tomography
• Magnetic Resonance Imaging
• Diagnostic Ultrasound

Biopsy

• Histological evidence is crucial in cancer diagnosis.
• Types of biopsies include incisional, excisional, fine needle aspiration, and core needle biopsy.

Cancer Diagnosis Pathway

• The pathway for cancer diagnosis from an interview, examination, diagnostic tests, to biopsy then a diagnosis

From Diagnosis to Staging

• Further imaging may be required for accurate staging after diagnosis.
• Staging establishes the extent of the disease.
• Staging helps with treatment plan determination, prognosis assessments, and evaluation and exchange of information between cancer centers.

Staging Investigations

• Sentinel node biopsy (determining cancer cell presence in lymph nodes)
• Medical imaging (bone scans, PET, CT, MRI) to identify spread location
• Bone marrow aspiration for biopsy and examination
• Pathology report confirming tumor size and growth into other tissues.

How Do Cancers Spread?

• Direct invasion
• Ductal infiltration
• Blood-borne spread
• Lymphatic spread
• CNS spread
• Transcoelomic spread

Staging: Numerical System

• Stage 0 (Carcinoma in situ) – early cancer confined to the layer it began.
• Stages I, II, and III (higher numbers show greater tumor size or spread to nearby tissues, lymph nodes)
• Stage IV – cancer spread to another organ

Staging Systems: TNM

• TNM staging (Tumor, Nodes, Metastases) - endorsed by UICC and AJCC.

TNM Staging: Tumor

• To = no primary tumor
• Tis = Carcinoma in situ
• T1 - Relatively small primary tumor
• T2 - Relatively large primary tumor
• T3 - Primary tumor invading neighboring structures
• T4 - large primary tumor, extensive spread
• Tx - inability to determine extent of primary tumor

TNM Staging: Nodes

• NO = no palpable lymph nodes
• N1 = movable lymph nodes on same side as primary tumor
• N2 = movable nodes on opposite side as primary tumor
• N3 = fixed nodes anywhere in the body
• Nx = unable to assess status

TNM Staging: Metastases

• MO = no distant metastasis
• M1 = distant metastasis present
• MX = unable to determine distant metastasis

Grading Tumors

• Histological grade is determined to create the treatment plan.
• Histological grade refers to cell differentiation (how similar the cancer cells are to normal cells)
  • The closer tumor cells resemble normal cells= better, less aggressive prognosis
• Grading is determined, and can't be assessed (grade GX)
• G1 = well-differentiated
• G2 = moderately differentiated
• G3= poorly differentiated
• G4 = undifferentiated

Gleason Grading

• Specifically used for grading prostate cancers
• Gleason scores 6 (group 1), 7 (group 2 and 3), 8 (group 4), 9 or 10 (group 5) reflect different cell appearance and likely growth rates

Practical Examples

• Breast Cancer Screening: NHS breast cancer screening for women aged 50-71, every 3 years.
  • Includes mammograms
• Breast Cancer Diagnosis: patient interview, physical exam, mammogram, ultrasound, MRI (in younger patients), FNA/core/excisional biopsy, diagnosis/grade results
• Breast Cancer Staging: TNM system used; lab tests (hormone status, FBC, liver function), imaging (CT chest, CT abdomen, bone scan)
• Prostate Cancer Screening: no reliable screening in UK but men aged 50+ can discuss PSA tests with a GP. Digital rectal exam is also an option.
• Prostate Cancer Diagnosis: patient interview, physical exam (rectal exam), lab tests (PSA), transrectal ultrasound guided biopsy, diagnosis of adenocarcinoma, grading.
• Prostate Cancer Staging: TNM system, lab tests (FBC), imaging (MRI pelvis, CT pelvis/abdomen, bone scan, PET, transrectal ultrasound).
• Lung Cancer Screening: targeted screening soon to be offered; people 55-74 who smoke or have smoked may be invited; lung health check to offer CT of the chest for high risk patients.
• Lung Cancer Diagnosis: patient interview, physical exam, lab tests (sputum cytology, spirometry), imaging (x-ray, CT, bronchoscopy, biopsy (CT/guided FNA/bronchoscopy biopsy; Diagnosis: SCLC, NSCLC), grading.
• Lung Cancer Staging: TNM system, lab tests (FBC, LDH, alkaline phosphate), medical imaging (MRI brain, CT/MRI abdomen, PET).
• Colorectal Cancer Screening: national bowel cancer screening program available in UK; those 60-74 receive a kit every 2 years, possible expansion to 50-59 soon
  • Includes stool sample analysis
• Colorectal Cancer Diagnosis: patient interview (rectal bleeding), physical exam (digital rectal, pelvic exam), lab tests (stool sample), colonoscopy, biopsy, diagnosis (adenocarcinoma), grading.
• Colorectal Cancer Staging: TNM system; lab tests (FBC, liver function test, CEA); imaging (chest x-ray, CT/MRI pelvis, PET/CT)